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Shaub AR, Lewis ET, Swetter SM. Patient Perceptions of Primary Care–Based Skin Cancer Screening. JAMA Dermatol. 2017;153(11):1192–1193. doi:10.1001/jamadermatol.2017.2527
Understanding potential screening-related patient harms is critical for implementation of United States Preventive Services Task Force recommendations, including skin cancer screening by primary care practitioners (PCPs).1 Between May 1, 2015, and August 30, 2016, we conducted a pilot study in a Veterans Affairs (VA) Health Care System to assess the feasibility of PCP skin cancer screening and education using the validated Internet-based Curriculum for Melanoma Early Detection (INFORMED) training module,2 which showed no significant differences in dermatology referrals or skin biopsies in the 14-month preintervention vs postintervention.3 To better understand patient perceptions of the screening experience, we interviewed 10 randomly selected patients who underwent PCP screening.
A semistructured interview protocol was used to elicit patient perceptions of the screening process and expected outcomes of clinical skin examination (CSE). The interviews were conducted by telephone 1 to 5 months postscreening and were 8 to 24 minutes in length. Interviews were recorded and transcribed verbatim. Interview transcripts were analyzed using a matrix4 to systematically code, compare, and identify subthemes of the matrix domains across interviews. The study was approved by the Stanford University institutional review board and VA Palo Alto Health Care System Research Administration.
Almost all patients (n = 9) reported experiencing a skin problem ranging from minor (eg, warts) to more concerning (eg, skin cancer) and had received a dermatology examination in the past, 3 patients routinely. All patients correctly identified at least 1 risk factor for skin cancer (eg, sun, age, family history), and 7 patients reported that they conducted skin self-examination (SSE) at least occasionally. Nine patients described changing into and out of gown for the examination as “not a problem,” although 1 patient reported being self-conscious because of his tattoos.
Nine patients reacted positively to having a PCP conduct a CSE. They described the exam as “thorough” and their health care provider as “very informative” and able to address any skin-related concerns. However, patients diverged as to whether they preferred to have a screening examination in primary care (n = 4) or preferred a combination of a PCP and dermatologist examination (n = 5). For example, one patient stated “I would rather just get it done with my doctor,”’ while another patient said an annual skin check “would be great” but that “it’d probably be better to be done by a dermatologist.” Patients expressed confidence that their PCP would refer if a problem were identified, although 2 patients expressed concern about other PCPs’ level of training to identify skin problems. Eight of 9 patients with a previous skin problem endorsed the importance of SSE and more frequent screenings.
Patients did not describe experiencing any harms from PCP screening (eg, discomfort about undressing, distress over referrals). Although they differed in their preference for which health care provider performed regular CSE, nearly all perceived it as a valuable addition to their existing health care. Our findings are compatible with a 2004 study by Federman et al5 that found low rates of patient embarrassment and high rates of perceived PCP thoroughness by performing CSE.
Additionally, most interviewed patients in our study expressed their willingness to conduct SSEs, highlighting the importance of clinician instruction of melanoma warning signs and SSE practices. Since barriers to PCP CSE include time limitations and clinician visits often focus on counseling over physical examination, patient identification of concerning lesions could promote earlier detection of melanoma and other skin cancers.6
Study limitations include interview participation by screened patients and not patients who opted out of screening. The sample size is small, and the pilot study was conducted at a single hospital, so patient and health care provider perceptions may not be generalizable.
Corresponding Author: Susan M. Swetter, MD, Department of Dermatology/Cutaneous Oncology, Stanford University Medical Center and Cancer Institute, 900 Blake Wilbur Dr, W3045, Stanford, CA 94305 (email@example.com).
Accepted for Publication: May 30, 2017
Published Online: August 2, 2017. doi:10.1001/jamadermatol.2017.2527
Author Contributions: Drs Shaub and Swetter had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Lewis, Swetter.
Acquisition, analysis, or interpretation of data: Shaub, Lewis.
Drafting of the manuscript: Shaub.
Critical revision of the manuscript for important intellectual content: Lewis, Swetter.
Administrative, technical, or material support: Swetter.
Study supervision: Swetter.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Andrea Nevedal, PhD, Center for Innovation to Implementation, VA Palo Alto Health Care System, for helping to design the interview templates. Dr Nevedal was not compensated for her contributions.
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